NUR 324 Nursing Process & Clinical Judgment Model

Question 1

The nurse is conducting an interview of a patient admission. Which data should the nurse document as subjective? 
A. Nausea
B. Light-headedness
C. 100.1 degree temperature
D. 120/80 BP 
E. Red rash
F. Discomfort in the stomach

Answer 1

A, B, F

Question 2

Which statement describes a characteristic of clinical judgment in nursing practice?

A. It is simple and easy to apply.
B. It is the foundation of safe, competent practice.
C. It provides standardization of treatment options.
D. It slows decision making to consider all factors.

Answer 2

B

Question 3

Name some nursing interventions.

Answer 3

Monitoring, teaching, education

Question 4

Nursing interventions: Independent vs. Dependent

Answer 4

Independent: assessment, monitor, and teaching –> VS, IO, height, weight
Dependent: requires the HCP –> labs, meds, treatments needed

Question 5

Do you need an order for PT? Chaplain?

Answer 5

yes, no

Question 6

KNOW: Nursing interventions are specific and need a time frame. SMART interventions.

Answer 6

Ex. teach about IS use, encourage use q 1 hour x 15

Question 7

Nursing Process: A.D.P.I.E.

Answer 7

A: Assessment
D: Diagnosis
P: Planning
I: Implementation
E: Evaluation

Question 8

Nursing Process: ASSESSMENT

Answer 8

• Gather information about the patient’s condition
• Picking up on cues that something is wrong with our patient

Examples: MAR, H&P, LABS, Diagnostic Tests

Question 9

Nursing Process: DIAGNOSIS

Answer 9

• ID the patient’s problems
• Do not use medical problem –>
• ——————-pneumonia NO
• ——————-weak cough, infection, poor lung sounds, fever YES

Example: Pain, respiratory function, managing xyz

Question 10

Nursing Process: PLANNING

Answer 10

• Set goals of care and desired outcomes
• SMART goals and outcomes: clear interventions, pt. centered

Ex. “Keep pt. pain level at a level 4 during the entirety of my shift.”
Intervention – “What will I do? Give pain med/tramadol”

Question 11

Nursing Process: IMPLEMENT

Answer 11

• Perform the nursing actions identified in planning
• Be specific: q6h, pain assessed q2h

Ex. Assess, monitor, implement, collab, teach, psychosocial

Question 12

Nursing Process: EVALUATE

Answer 12

• Determine if goals & expected outcomes are achieved

- Did it work? If not, how did we address this?

Question 13

Clinical Judgment Model

Answer 13

Recognize cues –> analyze cues –> prioritize hypothesis –> generate solutions –> take action –> evaluate outcomes

Question 14

CJM: RECOGNIZE CUES

Answer 14

• ID relevant clinical data, observe, assess

- Report, MAR, Labs

Question 15

CJM: ANALYZE CUES

Answer 15

Be able to interpret cues, organize & recognize patterns in order to link the pt.’s clinical presentation to a problem

• Clustering cues: SOB and Tachycardia go together

Question 16

CJM: PRIORITIZE HYPOTHESIS

Answer 16

Narrow problems down to the most pressing problem

What problem is the priority? Remember ABCs are top priority.

Question 17

CJM: GENERATE SOLUTIONS

Answer 17

Determine desired outcomes and the best solutions.
Determine what resources you may need.

Do you need to collab? Meds?

Question 18

CJM: TAKE ACTION

Answer 18

Implement nursing interventions based on your plan

Question 19

CJM: EVALUATE OUTCOMES

Answer 19

Compare observed outcomes to the desired/expected outcomes.

Did they work?

Question 20

What part of the CJM matches with ADPIE?

Answer 20

A - recognize cues 
D - analyze cues
P - prioritize hypothesis, generate solutions 
I - take action
E - evaluate outcomes

Question 21

After 0800 assessment, the nurse determined the patient is at risk for fluid imbalance.

What part of the nursing process did the nurse determine this in?
What step of the CJM is she in?

Answer 21

Diagnosis

Analyze cues

Question 22

What does SBAR stand for?

Answer 22

S - Situation
B - Background
A - Assessment
R - Recommendation

Question 23

SBAR: Situation

Answer 23

• Symptom/reason why you are calling HCP

“Hello HCP, this is Mary, Nursing Student, from 5 North. I am calling you about J.B. in room 531. As you might recall, he was admitted 2 days ago for a total knee replacement. I am calling you now because I am concerned that he is complaining of sudden SOA and severe chest pain while lying in bed.” “

Question 24

SBAR: Background

Answer 24

• Includes critical cues you gather to “persuade” the HCP is worth dialoguing about. Only include relevant info. Assessment goes here.

“Also, Mr. Brown’s lips are cyanotic (this is new) and his current O2 sats is 88% on RA where it has been 93%. His HR has also become tachy in the 110s and his RR is labored with a rate of 24 bpm. He was in normal sinus rhythm with no cardiac history that I am aware of at the time of admission.”

Question 25

SBAR: Assessment

Answer 25

• What you think is going on. May give diagnosis or be uncertain.

“I am concerned/I think that Mr. Brown may have/has a pulmonary embolus.”

Question 26

SBAR: Recommendation

Answer 26

• What you want done.
• “I think the following needs to be done… meds, labs, tests, assess pt…”
• Include timeframe in discussion
• Be sure that by the end of the call, it is specific and you know what is happening with you and the HCP.

“I’d like to start Mr. Brown on supplemental oxygen by face mask. Do you agree? Also, would you like me to order a immediate chest x-ray or CT scan?”